Student Travel Information and Insurance Form

Name *

First Name Last Name

Student ID # *

(Not your Social Security No.)

Phone Number *

Area Code Phone Number

Activity *

Email *

Activity Start Date *

Month Day Year

Activity End Date *

Month Day Year

Do you have any known health condition(s) that could affect you during this activity? *

Required Insurance Statement

All students participating in field trip at GTCC are advised to have health insurance. If you possess such insurance, please indicate below.

Name of Insurance Company (if you do not have insurance please enter N/A) *

Policy Number (if you do not have insurance please enter N/A) *

Waiver of Liability and Hold-Harmless Agreement for GTCC Approved Travel and Recreational Activities

In consideration of my being allowed the go on a field trip with GTCC I hereby agree to release and hold-harmless the Trustees of Guilford Technical Community College and each of the officers, staff, employees and other representatives of the College from any and all liability, claims and causes of action of any kind that I may have or that may arise out of my participation in the field trip/recreational activity. I also agree to indemnify GTCC for any action that may be asserted against them by reason of my participation.

This Release is binding on me, and my heirs, successors and assigns.

In signing this waiver, I acknowledge that I have read and that I understand the Waiver of Liability and Hold Harmless Agreement.

Signature *

Clear

Today's Date *

Month Day Year

**This form must be completed before any student is allowed to participate in organized, campus recreation programs.**

I understand that any travel advance made by GTCC is a loan and that I am personally responsible for all monies so advanced to me. If a travel advance is obtained and the trip to which the advance is made is not taken, I agree to repay the advance immediately. I understand that I have up to 30 days following completion of the trip to repay or substantiate the travel costs incurred by submitting a reimbursement form with required original receipts. I have examined this travel authorization request and agree to the terms and conditions.

Signature *

Clear

Today's Date *

Month Day Year

Advisors only

Please click on the link below to download and save the Travel Request and Form Reimbursement Form using your GTCC credentials. Fill out the travel information, print, sign on the bottom and send it to the Student Life Office via inter-office mail. Please contact Huma Asghar at extension 50173 or email hasghar@gtcc.edu with any questions.

Travel Request Form

Reimbursement Form

Student Travel Information and Insurance Form

Traveler's Agreement